Neuromodulation: An Option for Refractory Hand Pain?

Patients with chronic neuropathic hand pain may benefit from neuromodulation therapy when conventional treatments fail, according to a review published in the Hand Clinics.1

Neuromodulation devices designed to treat chronic pain deliver electrical current, or neurostimulation, to affected peripheral nerves or to the spinal cord, with the goal of preventing pain signals from reaching the brain.

A number of neuromodulation devices have been approved by the US Food and Drug Administration (FDA), and many more are in development. Interest in the alternative approach has grown with increasing evidence of the risks associated with long-term use of conventional analgesics, such as prescription opioids and nonsteroidal anti-inflammatory drugs (NSAIDs). Moreover, fewer than 50% of neuropathic pain patients achieve adequate pain control on pharmacologic therapy, suggesting a need for additional treatment options.1

Neuropathic hand pain has many potential causes. "It's an enormous category of pain," coauthor Porter McRoberts, MD, told Clinical Pain Advisor, citing several conditions that might be responsible for a patient's hand pain, including tendonitis, a pinched nerve, arthritis, or a tumor.

"The first step is to try to figure out what's causing the pain and then treat the underlying cause," Dr McRoberts explained. Depending on the cause, first-line management may consist of NSAIDs, opioids, physical therapy, surgery, or a combination of conservative strategies. If the pain persists despite treatment, or if the underlying condition is untreatable, the focus shifts to treating the pain with approaches such as spinal cord stimulation (SCS), he added.

Three types of neuromodulation can be used for patients with persistent hand pain, and treatment selection depends on the type of pain and treatment goals (Table).

"It is a very complex algorithm," said Dr McRoberts. "On the one hand, you have to consider the efficacy of the stimulation for treating the pain, and, on the other hand, you have to consider the difficulty or safety of the case." In most cases, however, patients receive cervical SCS, a treatment that has been used to treat a variety of pain types since the 1960s and thus far has shown the greatest level of efficacy in hand pain.1